Example: tourism industry
Guide to Performing a Root Cause Analysis (Revision 10-20 ...
Program and VHA Patient Safety Handbook 1050.01. Intended users of this guidebook include patient safety managers or any persons who may lead, facilitate, or participate in RCAs. Definitions for key terms in the guidebook can be found in the Glossary (Appendix A). Upon review of the guidebook, the user will understand each step
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Health care policy - VA National Center for Patient …
www.patientsafety.va.govIntroducing our new director, Robin Hemphill, M.D. By Joe Murphy, M.S., A.P.R., NCPS public affairs officer. On April 25, 2011, Dr. Hemphill became . the deputy chief patient safety officer and direc-tor, National Center for Patient Safety. She is also continuing her practice as an emergen-
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www.patientsafety.va.govFailure Mode and Effect Analysis (HFMEA™). Key aspects of the HFMEA™ process: HFMEA™ is a 5-step process that uses an interdiscipli-nary team to proactively evaluate a health care process. The team uses process flow diagramming, a Hazard Scoring Matrix™, and the HFMEA Decision Tree™ to
MODERATE SEDATION BY NON-ANESTHESIA PROVIDERS 1. …
www.patientsafety.va.govVeterans Health Administration Transmittal Sheet . Washington, DC 20420 December 30, 2014 . MODERATE SEDATION BY NON-ANESTHESIA PROVIDERS 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes the policy that defines the provision of moderate sedation by providers other than Anesthesiologists and Nurse Anesthetists. 2.
Guide to Performing a Root Cause Analysis (Revision 02/05 ...
www.patientsafety.va.govThe most commonly used comprehensive systematic analysis is the Root Cause Analysis (RCA). The RCA is a process for identifying the basic causal factor(s) underlying system failures and is a widely understood methodology used in many industries. Root cause analysis can be used to uncover factors that lead to patient
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www.patientsafety.va.govFalls Policy Overview The following is a suggested falls prevention policy. It is not required to be implemented. There are several areas that need to be covered in a falls prevention policy: I. Definitions of a Fall, Type of Falls, Severity of Injury . II. Fall Risk Assessment for Inpatients . III. Fall Risk Assessment for Outpatients . IV.
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